The serious detrimental effects of smoking after heart transplantation (HTX) are well established, but data that demonstrate the effects on female HTX recipients are scarce. The purpose of this study was to describe tobacco use, exposure to second hand smoke (ESHS), and health perceptions of female HTX recipients and examine relationships between these variables of interest and demographic and clinical characteristics of women following HTX. Seventy-two women (mean age, 54.3±12.7 years; mean time since transplant, 5.5±4.5 years) were enrolled from a single HTX center. Demographic and clinical data, tobacco use, ESHS, and health perceptions were obtained through self-report and chart reviews. Tobacco use was verified by measurement of urine cotinine levels. Twenty-four women were nonsmokers before and after HTX. Eighteen (37.5%) of the 48 women who were former smokers before HTX had returned to tobacco abuse. Only 4 of the 18 accurately reported their smoking behaviors. Forty percent of nonsmokers reported ESHS. Tobacco use and ESHS were highest among African American women. Forty percent of the sample perceived their health status as fair-poor; the remaining 60% reported good-excellent health. In a multivariate analysis, current tobacco use (odds ratio [OR], 5.20; confidence interval [CI], 3.83–9.13) and ESHS (OR, 1.82; CI, 1.17–2.82) were independent predictors of lower health perceptions. Although a majority of the female recipients who used tobacco ceased smoking before HTX, a substantial proportion demonstrated recurrent tobacco use after HTX. Our findings suggest the need for aggressive screening and risk factor interventions to promote smoking cessation before and after HTX in this unique population of female HTX recipients.